VTE Toolkit

Chapter Eight
Venous Disease Coalition
Safe Use of Oral Anticoagulants
VTE Toolkit
Action of Vitamin K Antagonists
• Inhibit the production of functional vitamin K dependent
clotting factors II, VII, IX, X
• Also inhibit the anti-clotting factors Protein C & S
• Initial changes in INR reflect inhibition of Factor VII
(shortest half-life); other factors take nearly a week to
decrease to thrombosis-preventing levels
• 20-fold or greater range in maintenance dose among
groups of patients (<1 mg/day to >20 mg/day)
• Contraindicated in pregnancy
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Mechanism of Action of Warafin
clotting factors
(II, VII, IX, X)
clotting factors
(II, VII, IX, X)
GIB = gastrointestinal bacteria
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Vitamin K Dependent Clotting Factors
II (Thrombin)
I (Fibrinogen)
Fibrin clot
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Factors Contributing to Patient
Variability in Warafin Dose
• Age
• Weight
• Race
• Liver disease
• Heart failure
• Genetics:
• Alcohol intake
• Nutritional status
• Diet
• Activity level
• Drug interactions
- cytochrome P450 2C9 polymorphisms (CYP 2C9)
- vitamin K epoxide reductase (VKOR) polymorphisms
• Patient compliance
• Who’s supervising anticoagulation
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Factors Increasing Bleeding Risk on
Oral Anticoagulants
Age > 75
Also receiving antiplatelet drugs
Uncontrolled hypertension
History of bleeding (GI, intracranial)
Chronic renal failure
Poorly controlled / poorly supervised
anticoagulant therapy
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Long-Term Treatment of VTE with a
Vitamin K Antagonist (Warafin)
• Target INR = 2.0 - 3.0
• Lower INR (1.5-1.9) is associated with increased
VTE recurrence, but NOT decreased risk of
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Warafin Therapy - Principles
• Patient and physician must be obsessive
• Do not order daily INR – use long-term trends
• Use a warfarin dosing sheet (for both MD and patient)
= a longitudinal record of doses, INR results, next INR
• Don’t over-react to just out-of-range INR values
• Stop ASA/clopidogrel unless indicated
• Manage hypertension aggressively
• Encourage vitamin K intake
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Diet and Warafin Use
• Do NOT advise restriction of vitamin Kcontaining food – this is associated with less
stable INR values
• Encourage foods high in vitamin K (broccoli,
spinach, brussel sprouts)
• “Let me know if you plan a major change in your
usual diet”
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Warafin and Alcohol
• Binge drinking  increases INR
 may reduce compliance
 increases UGI bleed risk
 reduces the stability of
• Recommend moderation NOT abstinence
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New Drugs and Warafin
• Assume new drugs might affect the INR
• For a known interaction (or uncertain):
- get INR 4-5 days after starting
• If INR was increased previously with the same
antibiotic, reduce warfarin dose for a few days
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ASA and Warafin Use
• Generally AVOID
• No additional benefit for most patients
• Definite increase in bleeding risk
• There must be a good reason for the ASA, e.g. coronary
artery stent, high-risk mechanical heart valve, acute
coronary syndrome, TIA/stroke on warfarin
• Therefore, the combination of an antiplatelet agent and
warfarin must be an ACTIVE decision
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NSAIDs and Warafin Use
• Not anticoagulants; minimal platelet inhibition
• Effect on INR unpredictable (may  it)
• Like all meds, there should be a good reason for the
• If starting regular NSAID use, check INR 4-5 days later
(if using PRN, don’t bother)
• If high-risk of GI bleeding  avoid or add PPI (age >60,
previous PUD, GERD, steroids)
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What to do if INR is not what
was expected
If the INR value is not what you
expected, ask the question,
“Why did this happen?”
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INR Higher than Expected
• Miscommunication about dosing by the doctor or patient
“Tell me what doses you’ve taken since the last INR”
• New medication – antibiotics, high dose acetaminophen,
amiodarone, NSAIDs, statins, omeprazole, over-the
counter drugs, herbals
• Substantial alcohol excess
• Inter-current illness
• Nutrition change – decrease vitamin K intake
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INR Lower than Expected
• Compliance
• Compliance
• Compliance
• Miscommunication about dosing by the doctor or patient
“Tell me what doses you’ve taken since the last INR”
• Nutrition change – increase vitamin K intake
• New medication – ginseng, green tea
VTE Toolkit
Reducing Warafin-Related
Bleeding in Practice
1. Things you CANNOT change
• age
• comorbid conditions
2. Things you CAN influence
• careful management of hypertension
• avoid combined ASA, other antiplatelets if possible
• excellent patient education
• obsessive supervision and tracking
• appropriate management of elevated INR
VTE Toolkit
Venous Disease Coalition
VTE Toolkit

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